Upload
jaheem-alligood
View
216
Download
0
Embed Size (px)
Citation preview
ADD Update
Kristi Maroni, MDLance Feldman, MD, MBA, BSN
Drs. Maroni & Feldman have no disclosures to report
Disclosures
Outpatient 4 physicians & 1 nurse practitioner 2 therapists
Inpatient 7N (24 adult beds) 7S (8 child / adolescent beds) Consultation service
Our Practice
1. Providers will be able to explain the diagnosis of ADHD
2. Providers will be able to understand the medical management of ADHD in children and adults
Goals & Objectives
Inattention: >/= 6 or more for children; >/= 5 for 17 and older and adults:
Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
Often has trouble holding attention on tasks or play activities. Often does not seem to listen when spoken to directly. Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace (e.g., loses focus, side-tracked). Often has trouble organizing tasks and activities. Often avoids, dislikes, or is reluctant to do tasks that require mental effort
over a long period of time (such as schoolwork or homework). Often loses things necessary for tasks and activities (e.g. school materials,
pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
Is often easily distracted Is often forgetful in daily activities.
ADHD Overview – Diagnostic Criteria
http://www.cdc.gov/ncbddd/adhd/diagnosis.html
Hyperactivity and Impulsivity: >/= 6 or more for children; >/= 5 for 17 and older and adults:
Often fidgets with or taps hands or feet, or squirms in seat. Often leaves seat in situations when remaining seated is expected. Often runs about or climbs in situations where it is not appropriate
(adolescents or adults may be limited to feeling restless). Often unable to play or take part in leisure activities quietly. Is often "on the go" acting as if "driven by a motor". Often talks excessively. Often blurts out an answer before a question has been completed. Often has trouble waiting his/her turn. Often interrupts or intrudes on others (e.g., butts into conversations or
games)
Diagnostic Criteria, Cont’d
http://www.cdc.gov/ncbddd/adhd/diagnosis.html
Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.
Diagnostic Criteria, Cont’d
http://www.cdc.gov/ncbddd/adhd/diagnosis.html
Forms (parent & teacher) Vanderbilt Connors
Testing Connors CPT Psycho-educational testing
Confirming a Diagnosis…
Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
Several symptoms are present in two or more settings (e.g., at home, school or work; with friends or relatives; in other activities).
Keep in mind possible secondary gain (NC controlled substance database)
Adult Onset vs. Child Onset
http://www.cdc.gov/ncbddd/adhd/diagnosis.html
Medication Therapy Behavior Modification
Treatment
Stimulants Methylphenidate people Dextroamphetamine people
Non-Stimulants Alpha 2 agonists Norepinephrine reuptake inhibitor
Medications
Methlyphenidate
Concerta Daytrana Focalin & Focalin
XR Metadate CD & ER Ritalin, Ritalin LA
& SR Quillivant
>6 y/o choose long acting first
Costs vary widely Method of
administration (tab, cap, liquid, patch)
Time release differences
Dextroamphetamine
Adderall & Adderall XR
Procentra (3 y/o!) Vyvanse
>6 y/o choose long acting first
Costs vary widely Method of
administration (tab, cap, liquid)
Vyvanse is a pro-drug
Alpha 2 Agonists
Intuniv (tenex / guanfacine) Once daily dosing
Kapvay (clonidine) More sedating BID dosing (if >0.1
mg)
6-17 y/o Monotherapy or
adjunct treatment Costly (consider
generics)
Ages 6+ Weight based dosing if <70kg
(start 0.5 mg/kg, max 1.4mg/kg) Increased risk of suicidality in
children/adolescents Norepinephrine reuptake inhibitor Non-stimulant alternative in adults Costly
Strattera (Atomoxetine)
Interpersonal interactions Study skills Organizational improvement Playing well with others Common cognitive distortions: all-or-nothing
thinking, mind reading, magnification and minimization, emotional reasoning, comparative thinking
Therapy Pearls
http://www.additudemag.com/adhd/article/912-2.html
Classroom seating assignment Minimize distractions Take frequent breaks Encouragement and positive reinforcement Parent skills training Partnering with teachers / co-workers
Behavior Modification
Methylphenidate v. Dextroamphetamine Stimulant v. Non-Stimulant Long acting first if >6 y/o Ages (3+, seriously…) Keep in mind dosing ranges
General Prescribing Thoughts…
When to switch or add adjunct tx 0 x 0 = 0
How to deal with side effects… Worsening of tics Exacerbation of mood / anxiety Sleep / Appetite
Deep Thoughts…
3+ medication failures Untoward side effects Significant treatment contraindications Concomitant mood or anxiety concerns
When to Refer…
Thanks!
Any Questions?